By Taylor Spencer
TIA – “This is Africa” – became an expression repeated multiple times during our stay in Uganda. I was part of a 4-member team lead by Dr. Mark Bisanzo, an attending at my medical school.The above expression served as a reminder to all of us that we were not in the United States anymore.
I spent one month working at Nyakibale Hospital, in the Rukungiri district, located in southwestern Uganda, not far from Rwanda or the Democratic Republic of Congo. Located 400 kilometers away from the capital city of Kampala, the Rukungiri district is home to 308,696 people in 70,158 households, from multiple tribes 1. The population density is one of the highest in rural Uganda, and is one of the poorest districts in the country. Though the climate is good for agriculture, most of the families dedicate their patch of land to crop farming. An ever-increasing population and land scarcity have forced the migration of male labor, in turn often leaving wives and their children to support themselves on the available family land. There has been migration and resettlement, programmed and spontaneous, leading to a certain degree of economic and social instability, which ultimately impacts the health of the population 1. However, it was not the limited resources, poverty, or the obscure medical conditions that created the greatest challenges for our group, as most of us expected. At least to me, the “challenge” was a matter of attitudes and perspectives – specifically, the attitude towards the patients from the Ugandan health care system, observed from an admittedly sheltered American medical student perspective.
To some degree, attitudes are expected to change as a function of experience. Take life and death. As a future doctor, I will deal with dying patients, and some of the experiences will be particularly difficult. For example, I would consider watching a child die to be devastating. However, in Africa this is a common experience. As one nurse told us, “this is Africa – people die.” In Africa, the reality of the facts is inescapable. Life expectancy at birth in Uganda is around 49 years. Child mortality is almost 140 of every 1000 births 2. Knowing these facts beforehand did not make the reality of what Ugandans have to face every day any easier to witness. For instance, we were faced with a 4 day-old child with what appeared to be on X-ray a classic case of Hirschsprung’s disease. The child would most definitely require surgical intervention at the government hospital in Mbarara. The cost of transportation was a bit over 20,000 Ugandan shillings (UGX), or $12 USD. Had one of the members of our team not volunteered the money, the mother would have had to stay at our hospital. Had the mother stayed, we would have done all that we could, but the treatment is still a surgery that we were not equipped for, and the child would have most likely die in the hospital. But if you have ten children, the Ugandan nurse explains, you cannot go broke at the expense of the other children just to save one more. Even if the mother had the 12 dollars at her disposal, spending them would mean a death sentence for everyone in the family. Though I could comprehend the context in which $12 could mean life or death, I felt uneasy about witnessing such a decision. Life and death, it seems, are approached a bit differently in Uganda.
But my frustrations went beyond facing life or death. One night we were called to examine a patient who presented with a large head laceration. By the time we arrived just minutes later, we found the patient lying on the bed bleeding excessively, all the while unattended. The nurse, on the other hand, had opted to go into the other room to read the newspaper. A week or so before our departure, our attending addressed the nursing students with us in the morning rounds. The previous night, we had written orders for serial blood cultures on one patient, fluids for another, and NPO (Latin for “nothing by mouth”) for a little girl who had pierced the posterior wall of her throat. Having barely missed rupturing her carotid artery, she was at risk for retropharyngeal infection. To our dismay, none of these orders had been followed. Our attending told the nursing students that in a few days we would be returning to the United States, and the hospital’s surgeon would too be departing soon. “You will be responsible for the care of these patients. Treat these patients like they are your family”, he said, scolding them. “You would not want your family member laying here neglected, would you? And I do not want to hear any of that ‘They are only peasants’ stuff!” Later on, I learned the “they are only peasants” theme is a common excuse used by some staff members to justify poor patient care. Much of Ugandan society is based on subsistence farming with relatively few skilled professionals. As such, nurses are part of an upper crust of society in rural Uganda, with more education than just about anyone else around. In a system rife with inequality, these attitudes went against what I have come to expect in my medical training.
It would be a broad overgeneralization to say this sort of attitude was always present, especially given my short stay. I can certainly think of many times that employees in U.S. hospitals are more laid back than they should be. And some of the Ugandan hospital staff, particularly a number of the young nursing students, seemed to exude initiative and enthusiasm. But far too often, an attitude of indifference permeated the medical care at Nyakibale Hospital and undermined the efforts of the harder working individuals. One bulletin board posted a notice that employees are not to sleep while on the job: “We have had several complaints from patients and attendants that at night they are unable to locate Hospital Nurses and Gatekeepers. ALL STAFF working evening or night shifts must remain awake and available for patients and attendants.” Still, when we were called in to care for patients at night, we had difficulty finding staff and the few we eventually did find were sleeping with head down on a desk. When you needed someone, you couldn’t count on them being there – they might be away tending cattle or preparing for a daughter’s wedding instead. Certain matters that tend to merit a sense of urgency in U.S. hospitals did not evoke the same response in Uganda, at least based on my experience.
Some of the challenges mentioned above have been addressed previously. An example is the book “The Man with the Key has Gone!” 3 by Dr. Ian Clarke, a physician that spent 20 years working in Uganda. The title apparently comes from a story that, as it was told to me, goes something like this:
“We need to do a procedure. Where is the equipment?”
“It is not here.”
“Can we get it?”
“It is in the room.”
“Can we go to the room?”
“It is locked”
“How can we get in?”
“There is a key.”
“Where is the key?”
“The key is with the man.”
“Where is the man?”
“The man with the key has gone.”
All too often, at least metaphorically, the “man with the key had gone” while we were trying to care for patients. And the man with the key seemed indifferent to his neglected duty.
During my stay, I had several moments of “culture shock”, such as the walks through town were everyone called out “Muzungu!” to the white people, our daily meals of matoke (steamed green plantains) with beans and rice, the unreliable electricity, and our spartan accommodations. But the real culture shock for me was in the hospital, in the care given to the patients. As an outsider, I must ask, were my expectations about working in Uganda idealistic? How could I juxtapose the attitudes I witnessed in Nyakibale Hospital with my preconceived notions about humanity in general and about Africa in particular? How much of my expectations for patient care were unrealistic? After all, I am early in my medical training and have much to learn. Who am I to impose any type of expectations on those that have been working in the trenches for many years?
We tried to take extra time to teach enthusiastic nursing students, to encourage and compliment their efforts, but oftentimes it felt like we could not encourage change in any meaningful way.
But how can someone engage the Ugandans – or any overworked rural healthcare worker, for that matter – in the process of enhancing the healthcare of their country? Perhaps I lacked perspective. The healthcare providers in Uganda have to perform against what seem to be insurmountable odds. In 2004, data shows just over 2200 physicians in Uganda, for a density of 8 per 100,000. Little more than 16000 nurses served the country. There were just 61 nurses per 100,000. And just 7.3% of the GDP was spent on health. The total per capita expenditure on health is close to $18 4. “Up country”, out of the big city, undoubtedly gets an even smaller piece of the pie. And this is without mentioning other problems such as HIV/AIDS or the internal conflicts that have caused over 1 million internally displaced persons (IDP). Against such odds, Ugandan healthcare workers are resilient to say the least, but even the toughest spirit can get disheartened.
In spite of all this adversity, the most rewarding aspect of working in Africa was caring for the patients. Despite some language barriers, cultural divides, and a length of stay limited to four weeks, I felt a stronger connection to my Ugandan patients than I feel for most of the patients in the United States. Perhaps the technology and efficiency of modern American medicine has hindered the personal connection between patient and physician. The opportunity to care for Ugandan patients, even the “peasants”, has provided some priceless memories.
However, for all my frustration when a patient’s needs were neglected, or when a nurse or physician demonstrated indifference, I felt a certain degree of helplessness. At times, the staff still slept, the patients were still called “only peasants”, and the orders went unfulfilled. For all the problems, the solutions are far from obvious, and perhaps even less able to be implemented. And yet, in spite of the challenges, four weeks in Uganda were amazingly rewarding. It was truly a spectacular experience, one that makes you want to do it again. TIA, after all.
Taylor Spencer is a medical and public health student at University of Connecticut. After completing the four years of medical school, he has participated in his school’s Enrichment Year program. In the course of the year, he traveled to various sites including his time in Uganda in October and November of 2007. He will be continuing his training in residency in Emergency Medicine at Albany Medical Center, and maintains a strong interest in international medicine. He can be contacted for questions or comments at trs418@aim.com.
References:
1. Rukungiri District Portal. Accessed online at http://www.rukungiri.go.ug/index.php on November 16, 2007.
2. UNICEF (2004). Uganda – Statistics. Accessed online at http://www.unicef.org/infobycountry/uganda_statistics.html on March 2, 2008.
3. Clarke I (2004) The Man with the Key Has Gone! New Wine Ministries.
4. World Health Organization (2006). Country Health System Fact Sheet: Uganda. Accessed online at http://www.afro.who.int/home/countries/fact_sheets/uganda.pdf on December 14, 2007.